Cirugía

URI permanente para esta comunidadhttps://hdl.handle.net/11441/10999

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2D ultrasound diagnosis of middle compartment prolapse: a multicenter study
(AME PUBL CO, 2022) García Mejido, José Antonio; González-Diaz, Enrique; Ortega, Ismael; Borrero González, Carlota; Fernández Palacín, Ana; Sáinz Bueno, José Antonio; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Medicina Preventiva y Salud Pública
Background: Recently, a specific methodology has been defined, using transperineal ultrasound, for the differential diagnosis of middle compartment prolapse [uterine prolapse (UP) or cervical elongation (CE) without UP] based on the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver, with a cutoff point of 15 mm. The objective of this study was to validate the diagnostic utility of a ≥15 mm difference between the pubis-uterine fundus distance at rest and during the Valsalva maneuver to define UP in a multicenter study. Methods: This prospective multicenter observational study included 94 patients (UP =51; CE without UP =43). The clinical examination was based on the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system for assessing pelvic organ prolapse (POP) and patients were candidates for corrective surgery of the middle compartment of the pelvic floor (correction of UP or CE without UP). The ultrasound study was performed by transperineal ultrasound (B-mode) with the patient undergoing dorsal lithotomy. The distance evaluation was performed in relation to the posteroinferior pubic margin in the midsagittal plane, with reference to the uterine fundus (established as the most distal hyperechogenic) line from the pubis to the uterine fundus at rest and with the Valsalva maneuver. We defined UP detected using UP as a difference of ≥15 mm between the pubis-uterine fundus distance at rest and with the Valsalva maneuver. Agreement between the clinical and ultrasound diagnosis of UP was assessed using the Cohen kappa coefficient of agreement and its 95% CIs. Results: The ultrasound diagnosis of global UP at the three centers showed very good agreement, with a kappa index of 0.826 (0.71, 0.94). The agreement of ultrasound with the clinical diagnosis of UP using the ICS POP-Q system was very good for each of the hospitals [Hospital 1: 0.814 (0.64, 0.98), Hospital 2: 0.847 (0.64, 1) and Hospital 3: 0.824 (0.59, 1)]. Conclusions: A difference of ≥15 mm between the pubis-uterine fundus distance at rest and during the Valsalva maneuver for the diagnosis of UP presents very good agreement with the results of clinical evaluation with the ICS POP-Q system.
A 5-year multicentre randomized controlled trial comparing personalized, frozen and fresh blastocyst transfer in IVF
(Elsevier, 2020) Simón, C.; Gómez, C.; Cabanillas, S.; Vladimirov, I.; Castillón, G.; Giles, J.; Fernández Sánchez, Manuel; Universidad de Sevilla. Departamento de Cirugía; Igenomix
Research question: Does clinical performance of personalized embryo transfer (PET) guided by endometrial receptivity analysis (ERA) differ from frozen embryo transfer (FET) or fresh embryo transfer in infertile patients undergoing IVF? Design: Multicentre, open-label randomized controlled trial; 458 patients aged 37 years or younger undergoing IVF with blastocyst transfer at first appointment were randomized to PET guided by ERA, FET or fresh embryo transfer in 16 reproductive clinics. Results: Clinical outcomes by intention-to-treat analysis were comparable, but cumulative pregnancy rate was significantly higher in the PET (93.6%) compared with FET (79.7%) (P = 0.0005) and fresh embryo transfer groups (80.7%) (P = 0.0013). Analysis per protocol demonstrates that live birth rates at first embryo transfer were 56.2% in PET versus 42.4% in FET (P = 0.09), and 45.7% in fresh embryo transfer groups (P = 0.17). Cumulative live birth rates after 12 months were 71.2% in PET versus 55.4% in FET (P = 0.04), and 48.9% in fresh embryo transfer (P = 0.003). Pregnancy rates at the first embryo transfer in PET, FET and fresh embryo transfer arms were 72.5% versus 54.3% (P = 0.01) and 58.5% (P = 0.05), respectively. Implantation rates at first embryo transfer were 57.3% versus 43.2% (P = 0.03), and 38.6% (P = 0.004), respectively. Obstetrical outcomes, type of delivery and neonatal outcomes were similar in all groups. Conclusions: Despite 50% of patients dropping out compared with 30% initially planned, per protocol analysis demonstrates statistically significant improvement in pregnancy, implantation and cumulative live birth rates in PET compared with FET and fresh embryo transfer arms, indicating the potential utility of PET guided by the ERA test at the first appointment.
A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation
(Wiley Open Access, 2019) García Mejido, José Antonio; Fernández Palacín, Ana; Bonomi Barby, María J.; Castro, Laura; Aquise, Adriana; Sáinz Bueno, José Antonio; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Medicina Preventiva y Salud Pública
Introduction: Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. Material and methods: Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group. Results: In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71. Conclusions: We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery.
A comprehensive WGS-based pipeline for the identification of new candidate genes in inherited retinal dystrophies
(Nature Portfolio, 2022) González del Pozo, María; Fernández Suárez, Elena; Bravo Gil, Nereida Inés; Méndez Vidal, Cristina; Martín Sánchez, Marta; Rodríguez de la Rúa Franch, Enrique; Ramos Jiménez, Manuel; Morillo Sánchez, María José; Borrego, Salud; Antiñolo Gil, Guillermo; Universidad de Sevilla. Departamento de Cirugía
To enhance the use of Whole Genome Sequencing (WGS) in clinical practice, it is still necessary to standardize data analysis pipelines. Herein, we aimed to define a WGS-based algorithm for the accurate interpretation of variants in inherited retinal dystrophies (IRD). This study comprised 429 phenotyped individuals divided into three cohorts. A comparison of 14 pathogenicity predictors, and the re-definition of its cutoffs, were performed using panel-sequencing curated data from 209 genetically diagnosed individuals with IRD (training cohort). The optimal tool combinations, previously validated in 50 additional IRD individuals, were also tested in patients with hereditary cancer (n = 109), and with neurological diseases (n = 47) to evaluate the translational value of this approach (validation cohort). Then, our workflow was applied for the WGS-data analysis of 14 individuals from genetically undiagnosed IRD families (discovery cohort). The statistical analysis showed that the optimal filtering combination included CADDv1.6, MAPP, Grantham, and SIFT tools. Our pipeline allowed the identification of one homozygous variant in the candidate gene CFAP20 (c.337 C > T; p.Arg113Trp), a conserved ciliary gene, which was abundantly expressed in human retina and was located in the photoreceptors layer. Although further studies are needed, we propose CFAP20 as a candidate gene for autosomal recessive retinitis pigmentosa. Moreover, we offer a translational strategy for accurate WGS-data prioritization, which is essential for the advancement of personalized medicine.
A large haematoma in abdominal wall after trocar insertion
(2008) Morales Conde, Salvador; Cadet Dussorf, Hisnard; Valera, Z.; López Bernal, Francisco; Universidad de Sevilla. Departamento de Cirugía
A map of human microRNA variation uncovers unexpectedly high levels of variability
(BMC, 2012-08-24) Carbonell, Jose; Alloza, Eva; Arce, P.; Borrego, Salud; Santoyo, Javier; Ruiz Ferrer, Macarena; Antiñolo Gil, Guillermo; Dopazo, Joaquín; Universidad de Sevilla. Departamento de Cirugía; Red Temática de Investigación Cooperativa en Cáncer (RTICC), Instituto de Salud Carlos III (ISCIII), Ministerio de Economía y Competitividad RD06/ 0020/1019
Background: MicroRNAs (miRNAs) are key components of the gene regulatory network in many species. During the past few years, these regulatory elements have been shown to be involved in an increasing number and range of diseases. Consequently, the compilation of a comprehensive map of natural variability in a healthy population seems an obvious requirement for future research on miRNA-related pathologies. Methods: Data on 14 populations from the 1000 Genomes Project were analyzed, along with new data extracted from 60 exomes of healthy individuals from a population from southern Spain, sequenced in the context of the Medical Genome Project, to derive an accurate map of miRNA variability. Results: Despite the common belief that miRNAs are highly conserved elements, analysis of the sequences of the 1,152 individuals indicated that the observed level of variability is double what was expected. A total of 527 variants were found. Among these, 45 variants affected the recognition region of the corresponding miRNA and were found in 43 different miRNAs, 26 of which are known to be involved in 57 diseases. Different parts of the mature structure of the miRNA were affected to different degrees by variants, which suggests the existence of a selective pressure related to the relative functional impact of the change. Moreover, 41 variants showed a significant deviation from the Hardy-Weinberg equilibrium, which supports the existence of a selective process against some alleles. The average number of variants per individual in miRNAs was 28. Conclusions: Despite an expectation that miRNAs would be highly conserved genomic elements, our study reports a level of variability comparable to that observed for coding genes.
A morphometric study of the secretory granules of the granular duct in the submaxillary gland of the rat following stimulation with noradrenalin and isoproterenol
(Universidad de Murcia.Departamento de Biología Celular e Histología. F. Hernández, 1990-08-29) Gutierrez Marín, María Soledad; Galera Ruiz, Hugo; Bullon, Pedro; Hevia Alonso, Antonio; Dorado-Ocaña, Manuel E.; Universidad de Sevilla. Departamento de Anatomía y Embriología Humana; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Estomatología; Universidad de Sevilla. Departamento de Farmacología, Pediatría y Radiología; Universidad de Sevilla. Departamento de Anatomía y Embriología Humana; Universidad de Sevilla. Departamento de Estomatología
In the present work, we carry out a morphometric analysis, at ultrastructural level, of the secretory granules of the granular undulated duct of the submaxillary gland of the rat, under basal conditions (Control Group or I), following stimulation for 10 minutes with 2 mg1100 g weight of Isoproterenol (Group 11), and following stimulation with 2 gamrnas/100 g weight of Noradrenalin for the same time as in the former case. It is seen that in general, Noradrenalin produces the appearance of a greater number of small granules than does Isoproterenol or the control group; and that Isoproterenol induces the presence of larger-sized granules than does Noradrenalin.
A multimodal database for the collection of interdisciplinary audiological research data in Spain
(Asociación Española de Audiología, 2024-09-27) Callejón Leblic, María Amparo; Blanco Trejo, Sergio; Villarreal-Garza, Brenda; Picazo-Reina, Ana María; Tena García, Beatriz; Lara-Delgado, Ana; Lazo-Maestre, Manuel; Sánchez Gómez, Serafín; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Enfermería
Hearing loss constitutes a major disability that hinders communica- tion and quality of life. Recent evidence has uncovered its impact on cognitive decline, thus highlighting its multifactorial dimension and the outstanding need for creating multimodal hearing data- sets that further cover clinical data across different health domains. The aim of this study is to develop a multi-collaborative database to systematically collect and analyze interdisciplinary data for audiological research, including auditory thresholds, speech tests, auditory evoked potentials, cognitive and quality-of-life tests, and medical images, among others. The database has been imple- mented in the Otorhinolaryngology Service of the Virgen Macarena University Hospital in Seville, integrated in the Intranet of the Andalusian Health Service, connected to the electronic patients’ medical records. This database relies on open-source software and complies with national and international guidelines on data protection. A specific registry module has been designed to auto- matically import auditory thresholds and auditory evoked poten- tials from clinical devices into the platform. A mobile app has also been implemented to collect questionnaires from patients remotely. A demo web version of the platform is freely available to the audiology community. The multimodal platform developed paves the way towards a multi-collaborative and unified framework for audiology research in Spain. Nevertheless, support from clini- cians and healthcare stakeholders remains critical to develop more evidence and high-quality multimodal open datasets in hearing research.
A Parametric Tool for Studying a New Tracheobronchial Silicone Stent Prototype: Toward a Customized 3D Printable Prosthesis
(MDPI, 2021-09-01) Zurita Gabasa, Jesús; Sánchez Matás, Carmen; Díaz Jiménez, Cristina; López-Villalobos, José Luis; Malvé, Mauro; Universidad de Sevilla. Departamento de Cirugía
The management of complex airway disorders is challenging, as the airway stent placement usually results in several complications. Tissue reaction to the foreign body, poor mechanical properties and inadequate fit of the stent in the airway are some of the reported problems. For this reason, the design of customized biomedical devices to improve the accuracy of the clinical results has recently gained interest. The aim of the present study is to introduce a parametric tool for the design of a new tracheo-bronchial stent that could be capable of improving some of the performances of the commercial devices. The proposed methodology is based on the computer aided design software and on the finite element modeling. The computational results are validated by a parallel experimental work that includes the production of selected stent configurations using the 3D printing technology and their compressive tes
A prospective observational study on the influence of the difficulty of forceps application and the avulsion of the levator ani muscle
(I R O G CANADA, INC, 2022) García Mejido, José Antonio; Fernández Palacín, Ana; García Jiménez, Rocío; Castro Portillo, Laura; Aquise, Adriana; Sáinz Bueno, José Antonio; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Medicina Preventiva y Salud Pública
Background: To compare the rate of levator ani muscle (LAM) avulsion between normal deliveries (ND) and forceps deliveries (FD) and to determine whether the difficulty of forceps application in FD is related to the occurrence of LAM avulsion. Methods: This prospective observational study included 240 primiparous patients (125 ND and 115 FD). FD were classified according to the difficulty of forceps application. The application was considered difficult if the fetal head was in a transverse position or if it was midforceps (head engaged by the leading part was above +2 stations) with the fetal head in the occipito-posterior position; otherwise, the application was considered easy. Ultrasound evaluation was performed 6 months after delivery, and complete avulsion was diagnosed when there was abnormal insertion of the LAM in all three central slices. Results: There were statistically significant differences between the ND and FD groups in the presence of LAM avulsion (15.6% vs. 38.3%; p < 0.0005), with a crude Odds Ratio (OR) of 3.36 and an adjusted OR of 4.219. However, there were no statistically significant differences in the LAM avulsion rates between the easy and difficult application groups (34.2% vs. 45.2%; p: 0.244). Conclusions: FD have higher rates of LAM avulsion than ND, although the difficulty of forceps application does not have an influence on the rates of LAM avulsion.
A randomized, controlled, first-in patient trial of choriogonadotropin beta added to follitropin delta in women undergoing ovarian stimulation in a long GnRH agonist protocol
(OXFORD UNIV PRESS, 2022) Fernández Sánchez, Manuel; Višnová, Hana; Larsson, Per; Yding Andersen, Claus; Filicori, Marco; Blockeel, Christophe; Pinborg, Anja; Khalaf, Yacoub; Mannaerts, Bernadette; Universidad de Sevilla. Departamento de Cirugía
STUDY QUESTION Does addition of choriogonadotropin beta (recombinant CG beta) to follitropin delta increase the number of good-quality blastocysts following ovarian stimulation in a long GnRH agonist protocol? SUMMARY ANSWER At the doses investigated, the addition of CG beta reduced the number of intermediate follicles and related down-stream parameters including the number of oocytes and blastocysts. WHAT IS KNOWN ALREADY CG beta is a novel recombinant hCG (rhCG) molecule expressed by a human cell line (PER.C6®) and has a different glycosylation profile compared to urinary hCG or rhCG derived from a Chinese Hamster Ovary (CHO) cell line. In the first-in-human trial, the CG beta pharmacokinetics were similar between men and women. In women, the AUC and the peak serum concentration (Cmax) increased approximately dose proportionally following single and multiple daily doses. In men, a single dose of CG beta provided higher exposure with a longer half-life and proportionately higher testosterone production than CHO cell-derived rhCG. STUDY DESIGN, SIZE, DURATION This placebo-controlled, double-blind, randomized trial (RAINBOW) was conducted in five European countries to explore the efficacy and safety of CG beta as add-on treatment to follitropin delta in women undergoing ovarian stimulation in a long GnRH agonist protocol. Randomization was stratified by centre and age (30–37 and 38–42 years). The primary endpoint was the number of good-quality blastocysts (Grade 3 BB or higher). Subjects were randomized to receive either placebo or 1, 2, 4, 8 or 12 µg CG beta added to the daily individualized follitropin delta dose during ovarian stimulation. PARTICIPANTS/MATERIALS, SETTING, METHODS In total, 620 women (30–42 years) with anti-Müllerian hormone (AMH) levels between 5 and 35 pmol/l were randomized in equal proportions to the six treatment groups and 619 subjects started treatment. All 619 subjects were treated with an individualized dose of follitropin delta determined based on AMH (Elecsys AMH Plus Immunoassay) and body weight. Triggering with rhCG was performed when 3 follicles were ≥17 mm but no more than 25 follicles ≥12 mm were reached. MAIN RESULTS AND THE ROLE OF CHANCE The demographic characteristics were comparable between the six treatment groups and the overall mean age, body weight and AMH were 35.6 ± 3.3 years, 65.3 ± 10.7 kg and 15.3 ± 7.0 pmol/l, respectively. The incidence of cycle cancellation (range 0–2.9%), total follitropin delta dose (mean 112 µg) and duration of stimulation (mean 10 days) were similar across the groups. At stimulation Day 6, the number and size of follicles was similar between the treatment groups, whereas at the end-of-stimulation dose-related decrease of the intermediate follicles between 12 and 17 mm was observed in comparison to the placebo group. In contrast, the number of follicles ≥17 mm was similar between the CG beta dose groups and the placebo group. A reduced number of intermediate follicles (12 to 17 mm) and fewer oocytes (mean range 9.7 to 11.2) were observed for all doses of CG beta compared to the follitropin delta only group (mean 12.5). The mean number of good-quality blastocysts was 3.3 in the follitropin delta group and ranged between 2.1 and 3.0 across the CG beta groups. The incidence of transfer cancellation was higher in the 4, 8 and 12 µg group, mostly as no blastocyst was available for transfer. In the group receiving only follitropin delta, the ongoing pregnancy rate (10–11 weeks after transfer) was 43% per started cycle versus 28–39% in CG beta groups and 49% per transfer versus 38–50% in the CG beta groups. There was no apparent effect of CG beta on the incidence of adverse events, which was 48.1% in the placebo group and 39.6–52.3% in the CG beta dose groups. In line with the number of collected oocytes, the overall ovarian hyperstimulation syndrome incidence remained lower following follitropin delta with CG beta (2.0–10.3%) compared with follitropin delta only treatment (11.5%). Regardless of the dose, CG beta was safe and well-tolerated with low risk of immunogenicity. LIMITATIONS, REASONS FOR CAUTION The effect of the unique glycosylation of CG beta and its associated potency implications in women were not known prior to this trial. Further studies will be needed to evaluate optimal doses of CG beta for this and/or different indications. WIDER IMPLICATIONS OF THE FINDINGS The high ongoing pregnancy rate in the follitropin delta group supports the use of individualized follitropin delta dosing in a long GnRH agonist protocol. The addition of CG beta reduced the presence of intermediate follicles with the investigated doses and negatively affected all down-stream parameters. Further clinical research will be needed to assess the optimal dose of CG beta in the optimal ratio to follitropin delta to develop this novel combination product containing both FSH and LH activity for ovarian stimulation. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by Ferring Pharmaceuticals, Copenhagen, Denmark. B.M. and P.L. are employees of Ferring Pharmaceuticals. M.F.S., H.V., C.Y.A., M.F., C.B., A.P. and Y.K. have received institutional clinical trial fees from Ferring Pharmaceuticals. C.B. has received payments for lectures from Organon, Ferring Pharmaceuticals, Merck A/S and Abbott. M.F.S. has received payment for lectures from Ferring Pharmaceuticals. Y.K. has received payment for lectures from Merck and travel support from Gedeon Richter. H.V. has received consulting fees from Oxo and Obseva and travel support from Gedeon Richter, Ferring Pharmaceuticals and Merck. C.Y.A. has received payment for lectures from IBSA, Switzerland. M.F and C.Y.A. were reimbursed as members of the Data Monitoring Board in this trial. M.F. has an issued patent about unitary combination of FSH and hCG (EP1633389). TRIAL REGISTRATION NUMBER 2017-003810-13 (EudraCT Number) TRIAL REGISTRATION DATE 21 May 2018 DATE OF FIRST PATIENT’S ENROLMENT 13 June 2018
A rare form of hereditary angioedema could be confused with ovarian cáncer
(IMR Press, 2021-04-14) Melero-Cortés, Lidia María; Rosso-González, María del Rosario; Frutos-Arenas, Javier; Silvan Alfaro, José Manuel; Martínez Maestre, María Ángeles; Universidad de Sevilla. Departamento de Cirugía
Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent and circumscribed episodes of subcutaneous and submucosal edema involving different organs. Gastrointestinal involvement usually presents as abdominal pain. The presence of ascites is rare with only few cases reported in the literature. We report a case of HAE with ovarian edema, ascites and elevation of CA-125 which led to an initial suspicion of ovarian neoplasia. It is important for gynaecologists to be aware of HAE, as this disease can present a symptomatology similar to that described in gynaecological diseases and therefore lead to unnecessary invasive procedures and delay proper treatment.
A simple model to predict the complicated operative vaginal deliveries using vacuum or forceps
(Elsevier, 2019) Sáinz Bueno, José Antonio; García Mejido, José Antonio; Aquise, Adriana; Borrero González, Carlota; Bonomi, María José; Fernández Palacín, Ana; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Medicina Preventiva y Salud Pública
Background: Complicated operative vaginal deliveries are associated with high neonatal morbidity and maternal trauma, especially if the procedure is unsuccessful and a cesarean delivery is needed. The decision to perform an operative vaginal delivery has traditionally been based on a subjective assessment by digital vaginal examination combined with the clinical expertise of the obstetrician. Currently there is no method for objectively quantifying the likelihood of successful delivery. Intrapartum ultrasound has been introduced in clinical practice to help predict the progression and final method of delivery. Objective: The aim of this study was to compare predictive models for identifying complicated operative vaginal deliveries (vacuum or forceps) based on intrapartum transperineal ultrasound in nulliparous women. Study design: We performed a prospective cohort study in nulliparous women at term with singleton pregnancies and full dilatation who underwent intrapartum transperineal ultrasound evaluation prior to operative vaginal delivery. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound (angle of progression, progression distance, and midline angle) was performed immediately before instrument application, both at rest and concurrently with pushing. Intrapartum evaluation of fetal biometric parameters (estimated fetal weight, head circumference, and biparietal diameter) was also carried out. An operative vaginal delivery was classified as complicated when 1 or more of the following complications occurred: ≥3 tractions needed; third- to fourth-degree perineal tear; severe bleeding during episiotomy repair (decrease of ≥2.5 g/dL in the hemoglobin level); or significant traumatic neonatal lesion (subdural-intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, or peripheral and cranial nerve injuries). Six predictive models were evaluated (information available in Table 2). Results: We recruited 84 nulliparous patients, of whom 5 were excluded because of the difficulty of adequately evaluating the biparietal diameter and head circumference. A total of 79 nulliparous patients were studied (47 vacuum deliveries, 32 forceps deliveries) with 13 cases in the occiput-posterior position. We identified 31 cases of complicated operative vaginal deliveries (19 vacuum deliveries and 12 forceps deliveries). No differences were identified in obstetric, neonatal, or intrapartum characteristics between the 2 study groups (operative uncomplicated vaginal delivery vs operative complicated vaginal delivery), with the following exceptions: estimated fetal weight (3243 ± 425 g vs 3565 ± 330 g; P = .001), biparietal diameter (93.2 ± 2.1 vs 95.2 ± 2.3 mm; P = .001), head circumference (336 ± 12 vs 348 ± 6.4 mm; P = .001), sex (female 62.5% vs 29.0%; P = .010), newborn weight (3258 ± 472 g vs 3499 ± 383 g; P = .027), and number of tractions (median, interquartile range) (1 [1-2] vs 4 [3-5]; P < .0005). To predict complicated operative deliveries, all 6 of the studied models presented an area under the receiver-operating characteristics curve between 0.863 and 0.876 (95% confidence intervals, 0.775-0.950 and 0.790-0.963; P < .0005). The results of the study met the criteria of interpretability and parsimony (simplicity), allowing us to identify a binary logistic regression model based on the angle of progression and head circumference; this model has an area under the receiver-operating characteristics curve of 0.876 (95% confidence interval, 0.790-0.963; P < .0005) and a calibration slope B of 0.984 (95% confidence interval, 0.0.726-1.243; P < .0005). Conclusion: The combination of the angle of progression and the head circumference can predict 87% of complicated operative vaginal deliveries and can be performed in the delivery room.
A teaching project on rectal cancer and concentration of procedures: a comparison of oncological results between Catalonia and the rest of autonomous communities
(Aran Ediciones, 2019) Codina-Cazador, A.; Biondo, S.; Espín-Basany, E.; Enríquez-Navascues, J.M.; García-Granero, E.; Roig-Vila, J.V.; Buxó, M.; Spanish Association of Surgeons; Capitan-Morales, Luis-Cristobal; Universidad de Sevilla. Departamento de Cirugía
Introduction: the goal of this study was to compare the oncological results (local recurrence, metastasis and overall survival) obtained by the Proyecto Docente del Cáncer de Recto of the Spanish Association of Surgeons (AEC) (Proyecto Vikingo, PV) in Catalonia versus the rest of Spanish autonomous communities. Methods: the PV database includes 4,508 patients who underwent a curative resection between March 2006 and December 2010, from the first 59 hospitals included in PV; 1,163 were from Catalonia and 3,345 were from the rest of Spain. There was a minimum follow-up of five years. Results: in Catalonia, the five-year cumulative incidence was 8% (95% CI: 6.4-9.9) for local recurrence, 17.7% (95% CI: 15.4- 20.2) for metastasis and 75% (95% CI: 72.4-77.7) for overall survival. In the rest of autonomous communities, these figures were 7% (95% CI: 6.2-8.2) for local recurrence, 22.3% (95% CI: 20.7-23.9) for metastasis, and 71% (95% CI: 69.4- 72.9) for overall survival. Variables associated with tumor recurrence in PV included Hartmann’s procedure, intraoperative perforation and circumferential margin involvement. Conclusion: the results obtained by the Proyecto Docente del Cáncer de Recto were homogeneous between Catalonia and the rest of the autonomous communities.
Abdominal wall surgery in bariatric patients
(AME, 2021) Morales Conde, Salvador; Licardie, Eugenio; Socas Macías, María; Barranco, Antonio; López Bernal, Francisco; Alarcón, Isaías ; Universidad de Sevilla. Departamento de Cirugía
Morbid obesity is one of the main factors related to hernia recurrences after an open repair, while laparoscopic approach has offered excellent results in this type of patients. Concomitant laparoscopic bariatric procedure and ventral hernia repair (VHR) with intraperitoneal mesh has been described as a safe option, but the need to place a mesh intraperitoneally has arisen some concerns. However, the literature does not show good results with the use of transfascial suture neither for primary closures nor with biological meshes. There is still not enough evidence to reach a consensus regarding when is the best time to perform the hernia repair on patients undergoing bariatric surgery, simultaneously or differing the hernia repair. For that reason, it seems that an individualized approach is recommended, informing the patient of the risks and benefits of each option. The type of bariatric surgery, the type and location of the hernia, previous surgery in case of an incisional hernia, symptoms related to the hernia and the surgical approach are factors to be analyzed. It is necessary to consider repairing simultaneously a ventral hernia (VH) in the patient who is going to undergo a bariatric procedure or differing it in order to perform simultaneously a concomitant repair (CR) and the dermolipectomy needed after weight loss. For this reason, only clear symptomatic hernias are recommended to be repair during the bariatric procedure. Finally, it is important to inform properly the patient about possible changes intraoperatively of the bariatric procedure because existing findings, especially due to the presence of adhesions.
Abordaje mininamente invasivo del carcinoma de endometrio: laparoscopia convencional frente a laparoscopia robótica
(2016-01-26) García Arreza, Aida; Martínez Maestre, María Ángeles; Coronado Martín, Pluvio J.; Universidad de Sevilla. Departamento de Cirugía
El cáncer de endometrio (CE) es la neoplasia del tracto genital femenino más común en los países desarrollados y la tendencia en los próximos años es que las cifras, tanto de casos nuevos como de mortalidad, sigan aumentando (1, 2). La piedra angular del tratamiento es quirúrgico, es la histerectomía total extrafascial, y debe realizarse linfadenectomía pélvica y paraórtica, según recomendación de la FIGO en lo tumores de tipo no endometrioide, y en los endometrioides de riesgo intermedio y alto riesgo (3), lo que supone la indicación de una cirugía de gran agresividad en pacientes a menudo de edad avanzada, con gran número de enfermedades concomitante, y con altas tasas de obesidad, y esto supone un mayor riesgo quirúrgico para la paciente, y a menudo cirugías se tornan un verdadero reto para el cirujano. Tradicionalmente, la cirugía del cáncer de endometrio ha sido la laparotomía, pero la laparoscopia ha demostrado ser una vía factible desde el punto de vista técnico, y segura desde el punto de vista oncológico, y con la que es posible disminuir drásticamente la morbimortalidad de estas pacientes por el tratamiento quirúrgico, permitiendo así un tratamiento adyuvante más precoz y en mejores condiciones físicas, en aquellas señoras en las que la cirugía no haya sido suficiente (4,5,6). Como aspectos negativos, la laparoscopia precisa de un grado de entrenamiento y destreza quirúrgica muy avanzados, incomodidadesergonómicas, y un mayor tiempo operatorio con respecto a la laparotomía (8). La cirugía robótica, permite una visión en 3D, con desaparición del temblor, movimientos intuitivos, y una curva de aprendizaje mucho más corta, entre otras ventajas. (9,10). Objetivo principal: - Comparar, en nuestro medio, los resultados quirúrgicos perioperatorios de dos modalidades de tratamiento mínimamente invasivo: la cirugía con teleasistencia robótica y la laparoscópica convencional, en el tratamiento del cáncer de endometrio. Objetivos secundarios: - Estudiar la supervivencia global y libre de enfermedad en nuestra población, determinar si afecta a la supervivencia el uso de una u otra vía quirúrgica. - Analizar si otros factores pueden afectar, independientemente de la vía quirúrgica seleccionada, a la supervivencia global o a la aparición de recaída. - Estudio de costes del tratamiento quirúrgico laparoscópico asistido por robot en las pacientes operadas de cáncer de endometrio en nuestro medio.
Abordaje robótico frente a abordaje laparoscópico con visión 3D en el tratamiento quirúrgico del cáncer de recto
(2022-05-19) Senent Boza, Ana; Jiménez Rodríguez, Rosa M.; Reyes Díaz, María Luisa; Portilla de Juan, Fernando de la; Universidad de Sevilla. Departamento de Cirugía
Introducción El cáncer de recto es una de las patologías malignas más frecuentes en nuestro medio y su tratamiento se basa en la cirugía. El abordaje laparoscópico del cáncer de recto ha demostrado unos resultados oncológicos equivalentes a los del abordaje clásico por vía abierta, con menores complicaciones postoperatorias y estancia hospitalaria. De manera paralela, el abordaje robótico permite realizar una cirugía oncológica de calidad, aportando ciertas ventajas: visión tridimensional y mayor rango de movimiento y estabilidad del instrumental y la cámara. Esto se traduce en menores tasas de conversión, aunque con un mayor coste. Los actuales sistemas de laparoscopia con visión tridimensional mejoran la percepción durante el procedimiento quirúrgico. Hay estudios que refieren una conversión y resultados postoperatorios y oncológicos similares entre los abordajes laparoscópico 3D y robótico en el cáncer de colon, aunque con un tiempo operatorio más largo y mayor coste con este último. Según esto, la laparoscopia con visión 3D podría aportar resultados equivalentes a los de la cirugía robótica también en el cáncer de recto, aunque hasta ahora no se han encontrado estudios publicados que comparen ambos abordajes en esta patología. Material y metodología Se llevó a cabo un estudio de intervención no aleatorizado, con diseño cuasiexperimental, en pacientes intervenidos de cáncer de recto con intención curativa en el Hospital Universitario Virgen del Rocío. Se incluyeron un total de 124 pacientes entre marzo de 2016 y noviembre de 2019, divididos en dos grupos de 62 pacientes: uno de abordaje robótico (ROB) y otro de abordaje laparoscópico con visión 3D (L3D). Todas las intervenciones quirúrgicas fueron realizadas por tres cirujanos con amplia experiencia en la cirugía del cáncer de recto mediante ambos abordajes. La variable principal del estudio fue la conversión a cirugía abierta. Se recogieron además variables demográficas y características del tumor, así como variables relativas al procedimiento quirúrgico, la evolución postoperatoria, las características anatomopatológicas del tumor y el seguimiento postoperatorio. Resultados El grupo ROB y el grupo L3D fueron comparables en cuanto características demográficas, clínicas y relativas al tumor. La tasa de conversión fue similar entre los dos abordajes (12,9% vs. 11,3%; p=0,783). El tiempo operatorio fue superior en el abordaje robótico (237 vs. 167 minutos; p<0001). No hubo diferencias entre los grupos en cuanto a complicaciones intraoperatorias, complicaciones postoperatorias, estancia hospitalaria, afectación de los márgenes radial y distal, calidad de la escisión mesorrectal ni supervivencia global y libre de enfermedad a 4 años. La conversión a cirugía abierta presentó mayor incidencia de complicaciones postoperatorias, mayor tasa de afectación del margen radial y peor supervivencia global y libre de enfermedad a 4 años que en los procedimientos completados por vía mínimamente invasiva. Conclusiones El abordaje laparoscópico 3D en el tratamiento quirúrgico del cáncer de recto presenta una tasa de conversión, una evolución postoperatoria y unos resultados oncológicos similares a los del abordaje robótico, con un tiempo operatorio inferior. La conversión a vía abierta en la cirugía mínimamente invasiva del cáncer de recto se asocia a peores resultados de evolución postoperatoria, recidiva neoplásica y supervivencia.
Abortos por incompetencia cervical. Tratamientos cruentos en el embarazo
(1971-03-28) Bedoya Bergua, Carlos; Bedoya González, José María; Universidad de Sevilla. Departamento de Cirugía
El papel del cuello uterino o cérvix en el embarazo, es complejo; debe mantener herméticamente cerrada la cavidad uterina o “estuche del huevo” y permitir que se amplíe considerablemente su luz, en el parto, para que a su través pase el feto. Es nuevo el conocimiento de que pueden producirse abortos por fracaso del sistema oclusor cervical. Las causas de aborto son múltiples y empiezan a entreverse solamente de un tiempo a esta parte; una de ellas es la llamada “incompetencia” o “insuficiencia” cervical. Se trata de un defecto de la oclusión o cierre (“Le verrou cervical” según Le LORIER9 especialmente a nivel del orificio cervical interno, (“internal incompetent cervical os” de los autores americanos) que impide la estanqueidad de la cervical uterina con lo cual, el huevo es expulsado al exterior. El concepto patogénico parece simplista u simplista resulta el tratamiento; pero es una realidad clínica, y la terapéutica es eficaz. La primera comunicación moderna y directa al respecto es la de PALMER y LACOMME en 1948; se trataba de una abortadora habitual después de haber tenido un parto con extenso desgarro del cuello, a la que hicieron una traquelorrafia adecuada, fuera del embarazo, y que después tuvo hijos vivos. Al parecer DOUAY había hecho 10 años antes (1938) una operación en un caso semejante, pero no dio cuenta de ella hasta la discusión del caso presentado por PALMER y LACOMME. Es verdad que HERMAN había llamado la atención, en 1902 ya, sobre la existencia de abortos causados por alteraciones anatómicas del cérvix y que había presentado hasta tres casos con abortos por desgarros cervicales tratados mediante traquelorrafía del clásico tipo de Emmet, con éxito en dos ocasiones. Y que también CHILD, en 1922, había establecido que el desgarro del oficio cervical interno era “una causa frecuente de aborto habitual”, recomendando la reparación del desgarro y la restauración del orificio cervical interno. Pero no es menos cierto que el concepto de “incompetencia” o “insuficiencia” cervical en el embarazo no era tenido en cuenta por los ginecólogos al enjuiciar las causas de aborto, y que interés por el problema se hizo patente solamente después de PALMER y LACOMME. El interés se acentuó cuando LASH y LASH, en 1950, establecieron la relación causal entre defectos cervicales y abortos habituales del 2º trimestre del embarazo, contribuyendo mucho a la difusión de este concepto entre los ginecólogos, especialmente entre los norteamericanos. Todavía se acentuó mucho más este interés cuando SIRODKAR describió en 1955, una técnica quirúrgica simple, para ser realizada durante el embarazo cuando el cuello era incompetente, presentando además una extensa estadística de casos con buenos resultados. Las comunicaciones abundan mucho después, como puede juzgarse para la relación bibliográfica que acompañamos, especialmente en el último decenio, sobre todo ha preocupado mucho en algunos países (Estados Unidos de América, Francia, Italia); no tanto en otros (Inglaterra, Alemania, Países Escandinavos, Rusia, etc.). En España la experiencia más extensa, con cifras parangonables a las mayores extranjeras, es la de ALBEA. Comunicaciones de muy reducido número de casos han sido hechas por BONILLA y cols., LOPEZ FERNANDEZ y ESCUDERO (de nuestra clínica), PARACHE y VARELA, RODRIGUEZ SORIANO y MARQUEZ, USANDIZA y PERAL. La experiencia adquirida en nuestra clínica durante los últimos años nos parece digna de ser tenida en consideración. CONCLUSIONES 1. El aborto por incompetencia cervical es una entidad clínica evidente. Aunque no sea una causa frecuente de abortos, es una causa específica que debe ser tenida en cuenta. 2. Por el hecho de ser susceptible de un tratamiento específico que es, además, eficaz en un alto procento de decisiones, merece aún más ser considerada esta causa de abortos. 3. La clínica (historia de abortos tardíos de fetos generalmente vivos) es bastante expresiva y puede justificar, por sí sola, el tratamiento específico. 4. De los medios diagnósticos utilizables fuera del embarazo, el más objetivo es la histerografía con contraste para ver la amplitud cervical, pero no tiene valor concluyente. 5. El método diagnóstico más seguro es la percepción al tacto de una permeabilidad anormal del conducto cervical en el embarazo. Para descubrirla se necesita realizar periódicamente su exploración a partir del 3º mes de gestación. 6. El proceder terapéutico que más rinde es el cruento “cerclage”, con alguna de las variantes técnicas propuestas. La más simple y menos cruenta es la de Mc Donald que no resulta menos eficaz. 7. El cerclage es más eficaz cuando se practica cuando el cuello está aún poco dilatado (intervenciones “en frio”). La intervención “en caliente” conduce a muchos fracasos; a pesar de ello, debe hacerse cuando por la razón que sea, no se ha hecho “en frio”. 8. Entre nuestras pacientes había 48 (de 78 estudiadas) en que la incompentencia cervical era “secundaria” a traumatismos, obstétricos o ginecólogos, sobre el cuello. Los demás casos (30 de 789 pueden ser catalogados de “incompetencia cervical primitiva”, sin antecedente traumático. 9. El procento de éxitos obtenidos en nuestro censo (70%) es similar al que se comunica por otros ginecólogos del resto del mundo. 10. Si se tiene en cuenta que entre los fracasos hay muchos en los que el cerclage se había hecho con estadio avanzado de dilatación (10% aproximadamente), la proporción de éxitos que debe esperarse cuando la intervención se realiza en circunstancias óptimas deber ser bastante mayor. 11. Con frecuencia relativa se asociaron, en nuestras pacientes, dos factores de aborto; el estado diabetoide gravídico y la incompetencia cervical. Ello significa que no debe olvidarse investigar y tratar uno aunque se haya descubierto y tratado otro. 12. Los fracasos que obtuvimos con el cerclage “en caliente” fueron muy numerosos, pero se obtuvieron algunos éxitos. Por eso, y porque no hay otro tratamiento, habrá que seguir haciendo cerclages “en caliente” cuando no se han hecho antes. 13. El cerclage es una intervención prácticamente desprovista de riesgos. No tuvo ninguno en nuestras pacientes ni tampoco se registran en la literatura. Es esta una razón más para hacerlo siempre que se plantee una indicación: incuso cuando esta no sea totalmente correcta. 14. El conocimiento de los abortos por incompetencia cervical y su tratamiento con el cerclage constituyen un paso hacia delante para reducir la proporción de abortos.
Absceso pancreático drenado en el conducto inguinal
(2002) Robles de la Rosa, J. A.; Docobo Durántez, Fernando; Durán Ferreras, Ignacio; Mena Robles, José; Bernal Bellido, Carmen; Álamo Martínez, José María; Universidad de Sevilla. Departamento de Cirugía; Universidad de Sevilla. Departamento de Anatomía y Embriología Humana
Abscesos cerebrales: Etiología, diagnóstico y tratamiento. Estudio durante los años 1979 a 1990
(1991-07-16) Cisneros, José Miguel; Loscertales Abril, Jesús; Revuelta Gutiérrez, Manuel; Universidad de Sevilla. Departamento de Cirugía
El pronóstico de los abscesos cerebrales (AC) ha mejorado significativamente en los últimos 15 años. Varios factores han contribuido a reducir la tradicionalmente elevada mortalidad y morbilidad de los AC: a) la tomografía axial computarizada (TAC), permitiendo realizar de manera incruenta el diagnóstico precoz y el seguimiento de los AC, b) el perfeccionamiento de las técnicas microbiológicas, especialmente de los métodos de cultivo para anaerobios, favoreciendo conocimiento del espectro etiológico de los AC y la realización de tratamientos antimicrobianos más correctos y específicos, c) la introducción del metronidazol y las cefalosporinas de tercera generación, ampliando notablemente el arsenal terapéutico de los AC y d) el desarrollo de nuevas técnicas neuroquirúrgicas, especialmente la cirugía estereotáxica, facilitando el abordaje de abscesos profundos y de pequeño tamaño, con extraordinaria precisión y seguridad. A pesar de estos avances la mortalidad y morbilidad continúa siendo considerable y quedan por aclarar importantes aspectos patogénicos y terapéuticos de los AC. La fisiopatología del absceso, en especial los mecanismos que inician y perpetúan la respuesta inflamatoria, son mal conocidos. La farmacocinética de los antimicrobianos en el material purulento de los abscesos no ha hecho más que empezar, y hasta el tratamiento de elección de los AC está por demostrar. La confirmación de que el tratamiento médico puede conseguir la curación de los AC, añade un elemento más a la ya vieja polémica de que método terapéutico, aspiración o excisión, es superior en tratamiento de os AC. En 1990, Brian Wispelwey iniciaba una excelente revisión de los abscesos cerebrales con la frase siguiente: “El absceso cerebral continúa siendo un desafío para la agudeza diagnóstica y la habilidad terapéutica del médico”. OBJETIVOS. 1. Estudiar los factores predisponentes y la etiología de los abscesos cerebrales en nuestra área geográfica. 2. Analizar los hallazgos morfológicos de la TAC y su utilidad en el diagnóstico y tratamiento de los abscesos cerebrales. 3. Evaluar los resultados obtenidos con los diversos métodos terapéuticos en los pacientes con abscesos cerebrales. 4. Finalmente, valorar la utilidad del protocolo de diagnóstico y tratamiento de los abscesos cerebrales. CONCLUSIONES 1. Los mecanismos patogénicos de los abscesos cerebrales estudiados son similares a los descritos, en cuanto a su tipo y frecuencia. 2. El correcto procesamiento de las muestras del pus del absceso cerebral, que incluya cultivo para anaerobios, aumenta la sensibilidad para el diagnóstico etiológico. 3. El tratamiento antimicrobiano previo a la toma de muestras del pus del absceso, no reduce de manera significativa la sensibilidad diagnóstica. 4. Los microorganismos más frecuentes han sido el grupo de Streptococcus intermedius y Bacteroides sp. entre los anaerobios, y Proteus sp. y Staphylococcus aureus entre los gérmenes aerobios. En un porcentaje considerable de casos la etiología es polimicrobiana. 5. El aislamiento de patógenos en focos de contigüidad puede tener una especificidad elevada para Proteus sp. en el exudado ótico y para Staphylococcus aureus en la herida quirúrgica. 6. Los síntomas neurológicos predominan sobre los signos sistémicos de infección en los abscesos cerebrales. La presencia inicial de signos neurológicos focales se asocia al desarrollo posterior de secuelas. 7. La tomografía axial computarizada permite analizar las características y localización del absceso cerebral en todos los casos, cuando se realiza con contraste. 8. El tiempo de evolución de los síntomas es de gran utilidad para estimar el estadío del absceso en la imagen tomográfica. Aquellos casos con menos de 14 días de evolución presentaban con mayor frecuencia absceso en fase de cerebritis, y aquellos con más de 14 días presentaban con mayor frecuencia absceso en fase de cápsula. 9. La desaparición de las imágenes patológicas en la tomografía axial computarizada cerebral ocurre con posterioridad a la curación clínica. La persistencia de edema cerebral asociado a las imágenes de realce advierte del riesgo de recidiva. 10. La cefalosporinas de tercera generación asociadas a metronidazo son al menos tan eficaces y seguras como la asociación de penicilina G y cloranfenicol. Las diferencias etiológicas encontradas dependiendo del foco primario de infección, determinan la elección del tratamiento empírico inicial. 11. La duración del tratamiento antimicrobiano debe tener una duración mínima de cuatro semanas, para conseguir la curación completa del absceso y evitar la recidiva. 12. El tratamiento médico exclusivo consigue la curación del absceso cerebral en pacientes seleccionados. Los principales criterios de selección incluyen la situación neurológica estable del paciente y los abscesos de tamaño pequeño y en fase de cerebritis. 13. La frecuencia de déficits neurológicos permanentes es mayor con la excisión quirúrgica que con la aspiración, así como en los pacientes tratados con uno de estos dos procedimientos cuando se comparan con los que recibieron tratamiento médico exclusivo. El tipo de tratamiento empleado (quirúrgico o médico) no influye en las frecuencias de recidiva y de mortalidad. 14. El estudio prospectivo de los pacientes ha influido en los siguientes aspectos del diagnóstico y tratamiento de los abscesos cerebrales: a. Ha contribuido a mejorar el procesamiento microbiológico de las muestras y el número de diagnósticos etiológicos. b. Ha favoreció el tratamiento médico exclusivo o asociado a aspiración frente a la excisión quirúrgica. c. Ha reducido la mortalidad y las recidivas en nuestros pacientes.

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